结肠憩室炎非手术治疗后的再入院和急诊手术风险：一项基于人群的分析。
Risk of readmission and emergency surgery following nonoperative management of colonic diverticulitis: a population-based analysis.
作者信息
Li Debbie, de Mestral Charles, Baxter Nancy N, McLeod Robin S, Moineddin Rahim, Wilton Andrew S, Nathens Avery B
机构信息
*Department of Surgery, University of Toronto, Toronto, Ontario, Canada †Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada ‡Department of Surgery, Institute of Health Policy, Management and Evaluation, Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada §Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada ¶Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada ‖Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; and **Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
出版信息
Ann Surg. 2014 Sep;260(3):423-30; discussion 430-1. doi: 10.1097/SLA.0000000000000870.
OBJECTIVE
To characterize the clinical course of patients with diverticulitis after nonoperative management and determine factors associated with readmission and subsequent emergency surgery.
BACKGROUND
Clinical course of this disease remains poorly understood; indications for elective colectomy are unclear.
METHODS
This was a retrospective cohort study of patients managed nonoperatively after a first episode of diverticulitis in Ontario, Canada (2002-2012). Time-to-event analysis and Fine and Gray multivariable regression were used to characterize the risks of readmission and emergency surgery for diverticulitis, accounting for death and elective colectomy as competing events.
RESULTS
A total of 14,124 patients were followed for a median of 3.9 years (maximum 10, interquartile range: 1.7-6.4). Five-year cumulative incidence was 9.0% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality. Patients younger than 50 years had higher incidence of readmission than patients aged 50 years and older (10.5% vs 8.4%; P < 0.001) but not emergency surgery (1.8% vs 2.0%; P = 0.52). Patients with complicated disease (abscess, perforation) were at increased risk of readmission than those with uncomplicated disease (12.0% vs 8.2%; P < 0.001), as well as increased risk of emergency surgery (4.3% vs 1.4%, P < 0.001). In multivariable regression, complicated disease and number of prior admissions were associated with increased risk of emergency surgery, yet age less than 50 years was not. Risks associated with complicated disease were nonproportional over time, being highest immediately after discharge and decreasing thereafter.
CONCLUSIONS
Absolute risks of readmission and emergency surgery are low after nonoperative management of diverticulitis, providing evidence for the practice of deferring colectomy for patients without persistent symptoms or multiple recurrences.
目的
描述非手术治疗后憩室炎患者的临床病程，并确定与再入院及后续急诊手术相关的因素。
背景
该疾病的临床病程仍了解不足；择期结肠切除术的指征尚不清楚。
方法
这是一项对加拿大安大略省（2002 - 2012年）首次发作憩室炎后接受非手术治疗的患者进行的回顾性队列研究。采用事件发生时间分析和Fine and Gray多变量回归来描述憩室炎再入院和急诊手术的风险，并将死亡和择期结肠切除术视为竞争事件。
结果
共对14124例患者进行了中位时间为3.9年的随访（最长10年，四分位间距：1.7 - 6.4年）。再入院的5年累积发病率为9.0%，急诊手术为1.9%，全因死亡率为14.1%。年龄小于50岁的患者再入院发生率高于50岁及以上患者（10.5%对8.4%；P < 0.001），但急诊手术发生率无差异（1.8%对2.0%；P = 0.52）。复杂疾病（脓肿、穿孔）患者的再入院风险高于非复杂疾病患者（12.0%对8.2%；P < 0.001），急诊手术风险也更高（4.3%对1.4%，P < 0.001）。在多变量回归中，复杂疾病和既往入院次数与急诊手术风险增加相关，但年龄小于50岁则不然。与复杂疾病相关的风险随时间不成比例，出院后立即最高，随后降低。
结论
憩室炎非手术治疗后再入院和急诊手术的绝对风险较低，为对无持续症状或多次复发患者推迟结肠切除术的做法提供了依据。
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